Orthopedic Coding Alert

Most Medicare carriers require that patients have at least one of the following five conditions to qualify for bone density screening (76075-76078, 76977, 78350-78351) reimbursement:

1. The patient is estrogen-deficient and at clinical risk for osteoporosis (733.00-733.09), based on medical history and other findings.
2. The patient has vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass) or pathologic vertebral fracture (733.13).
3. The patient receives glucocorticoid (steroid) therapy of 7.5 or more milligrams of prednisone (J7506) per day for more than three months.
4.Thepatient has primaryhyperparathyroidism (252.0).
5. The patient is being monitored to assess the response to any FDA-approved osteoporosis drug therapy.

Your local carrier may have more specific guidelines, so get your insurer's policy in writing before scheduling bone density screenings. Always maintain documentation demonstrating that the patient has one of these five conditions in case the scan is negative for osteoporosis. If the OIG subsequently audits your practice's bone density scanning claims, you can substantiate that the patient was sufficiently "at risk" for the service.